<%@ page language="java" import="java.util.*" pageEncoding="UTF-8"%>
<%
String path = request.getContextPath();
String basePath = request.getScheme()+"://"+request.getServerName()+":"+request.getServerPort()+path+"/";
%>


<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN">
<html>
  <head>
    <base href="<%=basePath%>">
    
    <title>My JSP 'chrdissynid_add.jsp' starting page</title>
    
	<meta http-equiv="pragma" content="no-cache">
	<meta http-equiv="cache-control" content="no-cache">
	<meta http-equiv="expires" content="0">    
	<meta http-equiv="keywords" content="keyword1,keyword2,keyword3">
	<meta http-equiv="description" content="This is my page">
	<link rel="stylesheet" href="css/pintuer.css">
    <link rel="stylesheet" href="css/admin.css">
	<link rel="shortcut icon" href="images/logo.jpg">
	<script src="js/jquery.js"></script>
	<script src="js/pintuer.js"></script>

  </head>
  
  <body>
    <div class="panel admin-panel">
		<div class="panel-head" id="add">
			<strong><span class="icon-pencil-square-o"></span>登记慢性病症</strong>
		</div>
		<div class="body-content">
			 <form  class="form-x" 
			       action="<%=basePath%>/chrd_sava.action" method="post">
				<div class="form-group">
					<div class="label">
						<label>慢病证编号：</label>
					</div>
					<div class="field">
						<input type="text" class="input w50" value="" name="chrd.chrdissynid"
							data-validate="required:数据必填项" />
						<div class="tips"></div>
					</div>
				</div>
				<div class="form-group">
					<div class="label">
						<label>慢性病编号：</label>
					</div>
					<div class="field">
						<input type="text" class="input w50" value="" name="chrd.illcode"
							data-validate="required:数据必填项" />
						<div class="tips"></div>
					</div>
				</div>
				<div class="form-group">
					<div class="label">
						<label>农合证号：</label>
					</div>
					<div class="field">
						<input type="text" class="input w50" value="" name="chrd.pycode"
							data-validate="required:数据必填项" />
						<div class="tips"></div>
					</div>
				</div>

				
				<div class="form-group">
					<div class="label">
						<label>疾病名称：</label>
					</div>
					<div class="field">
						<input type="text" class="input w50" value="" name="chrd.illname"
							data-validate="required:数据必填项" />
						<div class="tips"></div>
					</div>
				</div>
				<div class="form-group">
					<div class="label">
						<label>身份证号：</label>
					</div>
					<div class="field">
						<input type="text" class="input w50" value="" name="chrd.perscode"
							data-validate="required:数据必填项" />
						<div class="tips"></div>
					</div>
				</div>
				<div class="form-group">
					<div class="label">
						<label>操作人员：</label>
					</div>
					<div class="field">
						<input type="text" class="input w50" value="" name="chrd.creator"
							data-validate="required:数据必填项" />
						<div class="tips"></div>
					</div>
				</div>
				<div class="form-group">
					<div class="label">
						<label>起始时间：</label>
					</div>
					<div class="field">
						<input type="text" class="input w50" value="" name="chrd.starttime"
							data-validate="required:数据必填项" />
						<div class="tips"></div>
					</div>
				</div>

				<div class="form-group">
					<div class="label">
						<label>终止时间：</label>
					</div>
					<div class="field">
						<input type="text" class="input w50" value="" name="chrd.endtime"
							data-validate="required:数据必填项" />
						<div class="tips"></div>
					</div>
				</div>
				<div class="form-group">
					<div class="label">
						<label></label>
					</div>
					<div class="field">
						&emsp;&emsp;&emsp;&emsp;&emsp;<button class="button bg-main icon-check-square-o" type="submit">
							提交</button>
					</div>
				</div>
			</form>
		</div>
	</div>

  </body>
</html>
